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Abstract
Introduction Depression is a common mental health problem in both civilian and military populations. Access to evidence based psychological therapies for treating common mental health problems such as depression may not be adequate at present. Behavioural Activation (BA) represents a National Institute for Clinical Excellence recommended, evidence-based treatment for depression. The aim of this review was to review the literature to determine how BA could work as a therapeutic approach for military personnel with depression.
Method Five specialty-specific electronic databases were searched using the key words ‘behavioural activation’, ‘activity scheduling’ and ‘depression’. Emerging themes were drawn out of the literature using a long table approach to thematic analysis.
Results Seven themes were identified: Clinical Effectiveness, Cultural Competence, Co-morbidity, Cost Effectiveness, Alternatives to Face-to-Face Therapy, Training and Patient Experience.
Conclusions Group based BA is a cost effective option that may build upon service personnel's cultural affinity to teamwork and peer support. Brief training workshops and supervision could be provided to military mental health nurses to deliver group based BA. However service delivery may also be enhanced by enabling some nurses to specialise as Cognitive Behavioural Psychotherapists. More research is needed to understand whether this pragmatic, two pronged approach to training would result in the sustained dissemination of evidence based practice.
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Educational points
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Using BA as a psychological therapy option for treating depression may enhance DMHS current efforts to ensure that UK AF have access to evidence based treatments for depression.
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Where practical, a group-based version of BA could be delivered by generic military mental health nurses following a brief training package.
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The group based programme could be co-facilitated by nurse specialists trained as Cognitive Behavioural Psychotherapists who would be well placed to provide supervision and ensure fidelity to the evidence based BA model.
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For more distant units, individual therapy could be delivered remotely.
Introduction
The Defence Mental Health Services (DMHS) seek to deliver National Institute for Health and Clinical Excellence (NICE) recommended, evidence based psychological therapies.1 The DMHS falls under the command of Army Primary Healthcare and consists of Departments of Community Mental Health. Each department is staffed by psychiatrists, clinical psychologists, Mental Health Social Workers and mental health nurses who help individuals overcome a range of mental health difficulties.2 In the UK armed forces, many of those with mental disorders may not be seeking medical help for their symptoms.3
Within the UK, 2% of men and 3% of women are depressed. When mixed with anxiety this figure rises to 7% of men and 11% of women.4 A Department of Community Mental Health within a military setting reported that 19% of referrals within a 12-month period were for depression.2 These findings match government data on the number of referrals for depression within military personnel nationwide.5 Of note, the rate of psychiatric problems for service personnel returning from combat operations, including depression, is the same as for non-deployed service personnel.6
NICE produce guidelines for clinical practice that recommend behavioural activation (BA) as a treatment option for depression.7A behavioural explanation for depression is that it occurs because a person has experienced a reduction in behaviours or activities within their social environment that would normally help them to maintain a positive mood state (Figure 1). A common variable amongst depressed people is an increase in avoidance or escape behaviours.8 This means that they have less opportunities for the reinforcement of behaviours that help them to feel well, combined with a reduction in available behavioural strategies for coping with both positive and negative life events.9 Increasing opportunities for exposure to reinforcers of non-depressive behaviours and a reduction in behaviours that maintain depression may help somebody to overcome depression.9
Behavioural conceptualisation of depression. Adapted from Martell et al9
The purpose of this comprehensive review is to develop an informed understanding of how the DMHS can apply BA as an evidence-based psychological therapy for nurses treating depressed military personnel.
Methods
Search strategy
The following databases were searched: PubMed; EBSCO host (BNI; CINAHL; PsycInfo); Science Direct; Index to Theses; OpenSIGLE. The search words used were ‘Depression’, ‘Behavioral/Behavioural Activation’ and ‘Activity Scheduling’.
Inclusion/Exclusion criteria
The review included all studies involving BA as a treatment for depression either as the primary diagnosis or as a co-morbid problem. Studies involving BA were excluded if they did not refer to depression. BA was defined as an intervention where the primary focus was behavioural strategies aimed at increasing anti-depressant behaviours and reducing depressed behaviours.
Results
Twenty-six papers were identified that highlight seven themes that inform the following perspective upon how BA can work as a treatment for depressed service personnel (Table 1). The themes were:
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Clinical effectiveness
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Cultural competence
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Co-morbidity
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Cost effectiveness
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Alternatives to fact-to-face therapy
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Training
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Patient experience.
Studies included in this review
Clinical effectiveness
Efficacy is important within a military setting where a depressed service person may have a reduced medical category that could prevent them from deploying on combat duties. A clinically effective treatment will, hopefully, minimise the duration of an individual's reduced medical category. Three meta-analyses of BA were identified and demonstrated a large effect size for BA, whilst displaying no significant differences between BA and Cognitive Therapy.13–15 These reviews indicated a significant relationship between BA and the alleviation of symptoms of depression, with a large effect size and no significant difference when compared to other effective therapies.
Cultural competence
Subcultures are unique population segments from within the wider society that share a way of life, customs and ideas.16 Examples of subcultures include occupational groups such as the military.17 Culturally competent services are increasingly being tailored to the needs of veterans.18 ,19 In addition, serving members of the armed forces are often supported by military mental health nurses both on combat operations20 and in the UK.2 This suggests that they are being cared for by clinicians who have an understanding of their way of life, customs and ideas.
Group Behavioral Activation Therapy and Behavioral Activation for Latinos are examples of how versions of BA have been tailored to specific client groups.21 ,22 For example, the early involvement of family members due to their importance in Latino culture22 or making the session length the same as other lessons within a school setting21 have demonstrated improvements in outcome. This principle could be applied to a military setting, where military values could be accounted for within the treatment, hopefully, mitigating against potential cultural barriers to recovery.23 For example, including a work-based value such as returning to work or contributing to the team as an explicit goal for therapy might reduce absenteeism and help people to return to full duties.24
Co-morbidity
Post Traumatic Stress Disorder
Treating patients with Post Traumatic Stress Disorder (PTSD) and co-morbid depression using BA targets avoidance behaviours.25 The view that avoidance of reminders or memories of a traumatic event(s) contributes to the maintenance of PTSD is supported within the existing PTSD literature.26–28 However the difference between established treatments and BA is that the latter does not specifically confront trauma memories,29 focussing instead upon re-engaging with alternative, meaningful activities, such as take up hiking as opposed to hunting following a hunting accident.30 By comparison, military-specific approaches such as Eye Movement Desensitisation and Reprocessing31 or Cognitive Processing Therapy28 seem more likely to meet the aim of, where possible, either returning people to active duty or keeping them there in the first place.1
Chronic health problems
There have been 5631 service personnel medically evacuated from Afghanistan since 2006.32 Some of these individuals would have suffered serious battle injuries that result in chronic health problems, which in turn can negatively impact upon a person's mood and ability to function adequately within the context of their lives.33 A behavioural explanation is that it is due to a reduction in health promoting activities and BA can help people to re-engage with these activities.33 BA has been integrated into the treatment of obese patients with co-morbid depression, helping them to improve both their physical and mental health.34 Finally, BA has helped reduce the depressive symptoms that are associated with cancer.35 This means that BA could be adapted to help service personnel who have been injured in combat to both overcome their low mood and to adapt to their physical health problems.
Cost effectiveness
Four papers suggested that BA was a cost effective option.36–39 One study based this argument upon perceived cheaper training costs, but failed to substantiate this claim.37 Another compared the cost of BA to anti-depressants. Although BA has a higher initial cost, this evened itself out at the 9-month point and then antidepressants became increasingly expensive.39 A further study suggested that the economic benefits of helping people to recover Quality Adjusted Life Years outweighed the service delivery costs.36 This study went on to demonstrate that the costs were the same as ‘treatment as usual’ but with better treatment outcomes. A final study argued that BA was an effective group based therapy and was cost effective due to the higher ratio of patients to therapists (10 : 2 vs 1 : 1).38
Alternatives to face-to-face therapy
Group based therapy
The published treatment course length for this therapy ranges from 6 to 10 weeks, with each session lasting between 40–95 min.40 ,41 One study sought to ensure the group fitted in with the standard lesson timings in a school environment41 but no other study gave reasons for session timings. All of the studies identified were highly structured with set, therapist led, learning outcomes for each session. However BA in a group therapy format can still remain flexible to each attendee and provide opportunities for group processes to enhance outcomes.40 Different clients will move at different paces and grasp key concepts at different points using differing styles of learning.42 For example, difficulties in identifying appropriate therapy goals can take several sessions.33 Thus, although client's found the structure helpful,41 some stated that they would have liked more sessions.38 This means that some clients may need to repeat the group in order to have more time for learning, or go on to individual therapy.40 For some it may be that they simply find some sessions more relevant than other sessions.
Telephone based therapy
Telecommunications were being used to deliver therapy from start to finish43 or as part of a flexible approach to session delivery.44 ,45 Whereas Quijano et al44 gave no indication of decisional processes involved in why they opted for telephone contact with a specific patient, Wagner et al45 cited geographical distance and lack of means of transport. This suggests that telecommunications have the potential to overcome geographical and logistic barriers to care for depressed military personnel.
Training
Therapist training ranged from 6 hours46 ,47 to 5 days.48 Three of the studies described in detail the contents to their BA training,44 ,49 ,50 with key features being frequent supervision, modelling via video, live observation and role-play.49 ,50 These additional, constructivist learning approaches seek to include the student as an active participant.51 An additional feature that may also be useful in preventing skill fade and dealing with any common problems was bi-annual follow up training.44 As all the training packages were less than 1 week, it is clear that the approach can be quickly disseminated to clinicians, supporting prior claims to this effect.52 Of those studies that included people not trained in behavioural and cognitive psychotherapies, the outcomes were similar to other studies implying that efficacy can be maintained.44 ,46 In particular, experienced mental health nurses may deliver good outcomes when trained in this approach, using it daily and receiving frequent supervision.48 This final study is of particular interest because mental health nurses with limited training in Cognitive Behavioural Therapy (CBT) form the largest group of clinicians within DMHS.
Patient experience of behavioural activation
Four papers commented upon the patient experience within their narrative, which was largely positive.21 ,25 ,38 ,53 The goal orientated focus to treatment was specifically commented upon as being beneficial within both flexible25 and more structured approaches to BA.53 Mulick and Naugle25 elaborated upon this by stating that their client had felt more in control and an active participant in his own life. Having something concrete such as a workbook was a helpful part of the therapy process that participants felt able to make use of once therapy had finished.38 Finally, normalising mental distress and the treatment approach within the context of a group setting was also well received,21 as well might be an expected benefit of a group based intervention.54
Discussion
This comprehensive review has sought to synthesise available data about the efficacy and application of BA in order to offer a perspective upon how this psychological therapy can be applied to a military population. For the DMHS, two further questions can now be asked, the first being how BA could be delivered in a cost effective way and the second being how nurses could be trained in this approach?
BA is adaptable to a group therapy format and this is therefore a potential cost effective option for its delivery.21 ,33 ,38 ,40 ,41 There is a risk that cost might be considered the only reason for choosing group based versions of behavioural activation. However, some argue that it is the treatment of choice with comparable outcomes to individual therapy.54 This view is supported by the included studies that all demonstrate positive outcomes and by two meta-analyses that included group based interventions.13 ,14 In addition, peer support has been identified as one of the ways that military personnel manage psychological distress.55 This concept of peer support within military environments has formed the basis of the initial psychological management of traumatic events.56 This takes advantage of service personnel's affinity to teamwork,57 in the knowledge that it can result in less psychological distress.58 Thus, it seems intuitive to want to take advantage of this affinity for teamwork and peer support by treating depressed patients in a group setting with the added bonus of it being a more cost effective and resource efficient intervention.
Due to the nature of the military environment, many Departments of Community Mental Health are geographically distant from their clients. It is possible to deliver BA by telephone or video conferencing when geographical distance is an obstacle to accessing care.43–45 With improving telecommunications it may be possible to remotely deliver BA to a globally deployed warship or the rear echelon of a land-based operation.59 This presents a potential financial saving and an opportunity to promote resilience and recovery within the service person's normal occupational role.60 Interestingly, there is an example of this being positively received within a US military setting, with patients benefitting from more frequent appointments than would otherwise be possible.61 However, within the wider CBT literature the patients view on this approach has been mixed62 in spite of positive outcomes.63 This is suggestive of the need for further research within a UK Armed Forces setting that would need to encompass patient experience, benefit to the armed forces, efficacy and process issues.
While identifying a therapy approach is important, so is how competently this intervention might be delivered4 and how widely it is disseminated.64 ,65 The military research literature indicates that CBT is an underutilised treatment for common mental health problems and medication or counselling are used more frequently. This is of particular concern in the context of PTSD where CBT is recognised as a first line treatment.3 Of note, the UK Armed Forces have increased funding to address this issue by ensuring that all military mental health nurses have received a 5-day introductory workshop in CBT. In addition, some military mental health nurses are funded to undertake a postgraduate qualification in CBT and are eligible for accreditation with the British Association of Behavioural and Cognitive Psychotherapies (BABCP). However, there are inequalities in access to these nurse specialists.
Were the UK Armed Forces to support the wider dissemination of BA then it should be noted that the majority of studies within this review utilised psychotherapists or psychologists to deliver therapy even when claims were made about ease of dissemination to other clinical groups. However there are examples of both simplified versions46 and more complex approaches66 being delivered effectively by generic mental health nurses following a brief training package. Providing generic military mental health nurses with brief training in BA seems both a resource efficient and cost effective option. There is mixed support for brief training within the wider literature,65 with some studies having similar positive results64 ,67 but others having poorer outcomes.68 ,69 A key recommendation is that training should closely follow the evidence-based protocols and include on-going supervision.65
Due to the mixed support within the wider literature, the efficacy and sustainability of such interventions would need to be evaluated. More specifically this research would need to focus upon whether or not the treatment falls out of favour at some stage in preference of ‘treatment as usual’.65 ,70 By comparison, one benefit of continuing to fund some nurses to gain a postgraduate qualification in CBT and accreditation with the BABCP is that in order to maintain their accreditation, these nurse specialists will have to repeatedly demonstrate clinical competence, fidelity to CBT models, on-going CBT focussed supervision and annual CBT related continued professional development71 which would imply it is more difficult for the clinician to revert to ‘treatment as usual’.
Nurses trained as Cognitive Behavioural Psychotherapists, would have a broader set of evidence based CBT competencies (including BA) and psychotherapy meta-competencies that could be applied to a range of mental health problems.72 Indeed, attendance upon a formal CBT training programme has been identified as the key variable in developing broader competence as a Cognitive Behavioural Psychotherapist.73 One solution may be for nurse specialists to be evenly distributed throughout DMHS where they would be well placed to co-facilitate and supervise the delivery of a BA group alongside nurses who had attended a brief workshop. In addition, these nurse specialists may help to maintain a level playing field with civilian services within which a formal qualification in CBT has become a pre-requisite for delivery of evidence based therapy to patients with moderate to severe common mental health problems such as depression.18
Limitations to this study are recognised. Not all the databases produced the same articles, by selecting a limited range of databases there is a risk that some published studies have been missed.74 Other recommended search strategies include attempting to contact key figures within the field,75 a limitation to this study is that this was not done which risks publication bias. Finally, the review was carried out by a single researcher, resulting in a potential reviewer selection bias of available papers. Further research in this field is required, particularly comparing BA delivered on an individual basis to group therapy. In addition, remotely delivered psychotherapy is a novel approach within UK armed forces that would benefit from a direct comparison to face-to-face treatment.
Conclusion
No previous study has considered how BA can be applied as an evidence based psychological therapy for depressed military personnel. This review comes at a time when questions have been asked in the literature of how consistently military personnel, veterans and reservists are receiving evidence-based interventions for their common mental health problems. BA is a clinically effective intervention that can be delivered in a group setting. This is a cost effective means of delivering care that builds upon military personnel's cultural affinity to teamwork and peer support. Training military nurses in this approach may augment DMHS current efforts to ensure the dissemination of evidence-based practice.
Acknowledgments
The author would like to thanks Lydia Turner, Course Leader for the MSc in Cognitive Behavioural Therapy at the University of Brighton for her support in the production of this manuscript.
References
Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; externally peer reviewed.